Lose Yourself to Find Yourself

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Enlarge Image »Ellen Garfield, before and after bariatric surgery, with her son

When Ellen Garfield weighed nearly 400 pounds, the 39-year-old Bensalem mother often felt helpless. She had been heavy her entire life, joining Weight Watchers and Jenny Craig too many times to count, and trying Atkins and other diets without success.

Yet year after year she still managed to tell herself she would begin to eat right and do what was needed to lose the unwanted weight. “It never happened. Once you are that heavy, you can’t lose that weight on your own. You can lose 50 pounds, but it will come back,” she says.

The idea of having a surgical intervention was always on her mind, and in March 2010, when her son was 12, Garfield underwent bariatric surgery at Abington Hospital. The operation she had, the duodenal switch, is reserved for the heaviest patients. She has since lost 180 pounds — and seen several health problems disappear.

She recalls, “I left the hospital two days after surgery not being a diabetic or having high blood pressure.” Her goal was simple: to be around for her husband and son.

Even though there is no such thing as a typical weight-loss surgery patient, Garfield embodies some trends; the majority of people who have bariatric surgery are women in their childbearing years with obesity-related health problems.

Garfield feels fortunate to have found the program at Abington Memorial Hospital and in particular surgeon Fernando B. Bonanni, Jr., M.D. He is director of the hospital’s Institute for Metabolic and Bariatric Surgery. Before she could have the surgery, Garfield was required to receive a psychiatric evaluation, ultrasound and cardiac clearance, meet with a nutritionist, have blood work and get approval from her insurance company. She even had to take a test to prove she understood what she was getting into.

Still, she says, “The more I talked to others who had surgery done, the more I knew it was the right choice for me.”

Bonanni concedes that using surgery to combat morbid obesity is a radical idea. “What is even more radical,” he adds, “is that obesity is the second-biggest [health] problem in the world right now. We lose about 500,000 people a year — early in their lives — to it and it is not slowing down. It is the second most common cause of preventable death, second only to smoking, and soon it will exceed smoking.”

Surgical intervention isn’t for everyone. To qualify, people must be at least 100 pounds overweight, have a body mass index of at least 40 and have tried for five or more years to take off the weight. However, they can qualify with a lower BMI of 35 if they have hypertension, diabetes or heart disease. Of course, merely meeting benchmarks does not automatically make someone a good candidate. As Bonanni puts it, “Their commitment needs to be lifelong. The surgery is the least we have to do as time goes on. The most of what we do is keeping them compliant on the road to success. That’s going to be the hardest thing.”

When people attend free seminars given by John Meilahn, M.D., director of bariatric surgery at Temple University Hospital, he implores them to carefully consider the lifestyle changes they are willing to make. When people lie to themselves and fail to give up the foods that their post-operative smaller stomachs won’t be able to handle — such as cookies and ice cream — they can make themselves sick and defeat their surgeries. They also need to become more active, come for followup care and attend support group meetings.

Patients and surgeons usually settle on a specific option after considering the patient’s age, weight, health conditions, medications and past surgeries.

Still, as Meilahn says, “When you take 10 bariatric surgeons, they do the operation 10 different ways. So people really shouldn’t be lulled into thinking an operation is an operation is an operation. There are subtle differences in how you manage things and how you construct things that make a difference.” Meilahn suggests that patients ask how long surgeons have been doing the procedures, what results they have had, and what complications they have encountered.

Relying on advertising is not the best way to select a surgical center. David Metz, M.D., professor of medicine, division of gastroenterology at Perelman School of Medicine at the University of Pennsylvania, offers this advice: “The data are very definite. Experience counts. High-volume centers are the place to go. And it needs to be a multidisciplinary team. You can’t just have a surgeon who will do the operation, pop in and leave. You need nutritional support, psychiatric support, and you need medical monitors to work with the co-morbidity diseases.”

A red flag is raised when patients say they want a laparoscopic adjustable gastric band (more commonly known as a lap band) because it is minimally invasive, simple and problem-free. Meilahn says, “What they mean is ‘the band is going to do the work for me so I don’t have to work.’ And that’s a common misconception we find with the device-driven advertising.”

Even though bariatric surgeons prefer that patients keep an open mind about the various types of surgery that may be available to them, there are some basic details of what to expect, from the least complicated to the most involved methods.

Laparoscopic adjustable gastric band

While the patient is under general anesthesia, a hollow silicone band with a balloon inside is attached to the top of the stomach and fat that is present there. The band is connected to a small port implanted under the skin. By inserting a needle through the patient’s belly, the port can be used to add a saline solution to the band, making it tighter.

The lap band restricts the amount of food needed to be consumed to feel full. Patients with lap bands must cut their food into small pieces and avoid bread and other foods that can get stuck in the band. Surgery usually lasts about an hour and patients go home the same day or next morning.

Bonanni, who has performed 2,000 lap band insertions, says they are the least effective weight-loss surgery alternative. His patients lose an average of 35 to 45 percent of their excess body fat, not the 55 percent claimed by some band manufacturers. Frequent adjustments are needed, particularly as weight is lost and the fat that surrounds the band becomes thinner.

Vertical sleeve gastrectomy

After surgically removing 85 percent of the stomach, a small banana-shaped organ is created. It provides a similar restriction to the lap band, but without having a foreign body that may slip and need to be removed, Meilahn notes. For patients who take non-steroidal anti-inflammatories, the sleeve gastrectomy may be a better option than gastric bypass. On the other hand, people who experience frequent bouts of heartburn and reflux would not be good candidates. Patients usually go home the day after the 1.5-hour operation, which can help them lose up to 55 percent of their excess weight.

Gastric bypass

The most common form of bariatric surgery, gastric bypass involves creating a small stomach pouch and re-routing it to the small intestine. Since the small intestine is less efficient in absorbing nutrients the result is rapid weight loss. Gastric bypass patients who eat the wrong foods will pay for it by experiencing pain, abdominal cramping, diarrhea and lightheadedness, unpleasant symptoms that usually discourage them from doing so again. Vitamins and supplements will be required to make up for nutritional shortfalls. The two- to three-hour operation can help people lose 50 to 75 percent of their excess weight.

Duodenal switch

Geared to people who need to lose more than 150 pounds, and not widely performed, the duodenal switch is similar to the gastric bypass except it makes it even harder for the body to absorb nutrients. After the four-hour operation, food spends less time mingling with digestive juices in the intestinal tract. The good news is that 95 percent of diabetic patients who have the procedure will go into remission almost instantly. The surgery can lead to a person shedding 85 percent of their excess weight.

More than a year after Garfield’s duodenal switch, life has changed considerably for her. Because she can no longer eat as she did before, she focuses more on cooking than eating. Meals are much smaller than they used to be and she has six of them a day. When she travels on business she never forgets to bring along protein bars, protein powder and nuts.

What surprised her most about the surgery were the emotional changes she experienced in her relationships. For example, although her husband of 17 years has been supportive, it has been hard for him to watch her new self emerge.

“It’s been difficult for all of us, but in a good way,” she says. But with any luck there should be plenty of time to work things out.

Gail Snyder is a Chalfont-based freelance writer and frequent contributor to Special Sections.This article originally appeared in Perfect Fit, a special section of the Exponent.